Complete Care Management Services

Regardless of whether you are a patient, provider or payer, minimizing healthcare expenses in the acute and post-acute stage of recovery is a key objective. This becomes complicated in the case of patients with chronic diseases that require transitioning across different care settings and providers. However, unlike a primary care facility, where a hospitalist actively organizes a patient’s care management from a holistic perspective, post-acute institutions like long-term acute care hospitals (LTACs) and skilled nursing facilities (SNF) focus on moving patients to the next step in the care continuum. This siloed approach in post-acute care creates a segmented patient journey that leads to avoidable emergency department (ED) visits and readmissions, in turn, leading to higher healthcare expenses.

Complete Care Management Services’ (CCMS) novel, value-based, chronic care management model centers on dedicated central coordinators to connect different care provider segments spread across the patient’s rehabilitation continuum. With a focus on Medicare beneficiaries and Medicare Advantage enrollees, the company employs the latest technologies and analytics to reduce expenditures and improve outcomes.

CCMS’ chronic care model brings the benefits of the Center for Medicare and Medicaid Innovation’s (CMMI) new, end-to-end care management plan to the seriously ill population (SIP), driving a deeper understanding of social determinants, psychosocial issues and disease management. CCMS also implements patient- and data-centric frameworks to optimize data management and facilitate provider collaboration across the care continuum.

“Our innovative care model prioritizes the Triple Ps of healthcare. The patient wins through personalized care and improved outcomes, the provider wins with access to valuable data and information, and the payers win by avoiding costly hospital readmissions,” says Mario Espino, founder & chairman.

By equipping clients with a holistic chronic care management solution, CCMS offers a “win-win-win” scenario for patients, providers, and payers, where patients typically have minimal or no cost-sharing obligations and referring providers incur no financial responsibility for the services provided by CCMS. The impact of its model is supported by a recent study conducted by CCMS and a hospitalist group attached to a tertiary hospital in South Florida that showed how the use of the CCMS framework led to significant reductions in hospital visits and readmissions and a greater than 50 percent decrease in the need for additional care around post-acute discharges.

TARGETED APPROACHES TO PRIMARY CARE

In 2018, when Direct Contracting Entities and Primary Care First were introduced as substitutes for the Next Generation Accountable Care Organization (ACO) model, CCMS recognized a gap in care for the SIP, particularly in post-acute settings.
CCMS developed its care model to proactively and consistently treat patients’ chronic conditions and reduce preventable ER admissions and readmissions that typically drive high Medicare expenses.

Unlike the traditional reactive care model, CCMS’ patient-centered model addresses the underlying causes of medical conditions to prevent acute episodes and unexpected complications. By combining ongoing in-home and telehealth care management, remote vitals monitoring and timely therapeutic interventions, CCMS’ care model improves patients’ quality of life, which is underserved by the reactive care model.

“Our comprehensive package offers the flexibility to engage with patients in real time or, if necessary, provide direct consultation through our telemedicine tablets with customizable remote patient monitoring (RPM) tailored to each patient,” says Espino.

Designed to reduce care utilization through effective preventive medical measures and monitoring, CCMS’ chronic care management model enhances a doctor’s capacity to deliver desired outcomes. Creating a personalized plan, which includes building a dedicated and specialized care coordination team around the patient, CCMS care coordinators conduct regular in-person and remote medication reconciliation, real-time RPM, psychosocial services, and acute facility admission monitoring – among other care directives tailored to the patient’s needs and wellbeing. CCMS care coordinators are complemented by a dedicated team of nurses, who provide administrative oversight to ensure proper utilization management and superior quality assurance.

PRIORITIZING PATIENTS, EMPOWERING PROVIDERS AND REDUCING PAYER HEALTHCARE COSTS

CCMS’ visionary approach revolves around using technology and pioneering methodologies to transform the traditional in-home visiting physician model into a comprehensive end-to-end care management system that actively helps patients better manage their conditions. Central to this is the integration of advanced tools and platforms that collect and analyze patient data. Recognizing that vital signs are pivotal to the assessment of patient stability and disease progression, CCMS has developed and collaborated on/with sophisticated systems for real-time monitoring and evaluation.

Once a patient’s vital sign datasets have been consolidated, the data points are captured, organized, and presented in visual graphs that accurately represent a patient’s vital signs over time. CCMS’ collection and implementation of historical and real-time health data produces an augmented dataset that enables the patient’s care teams to detect trends, identify deviations, and make proactive interventions. The data-driven insights are then harnessed by CCMS’ multidisciplinary care coordination team, which span certified medical assistants, registered behavioral health therapists, referral and medical record coordinators, clinical reviewers, and transitional care experts.
STRATEGIES FOR CONTINUOUS CARE IMPROVEMENT

CCMS’ practices involve placing care managers within acute care facilities and extending their support into patient homes to create a protective shield that prevents patients from falling through the cracks of the healthcare system. Integrating behavioral health support across various care settings, CCMS emerges as a beacon of holistic care.

The impact of its integrated approach is profound, with significant reductions in acute-care admissions or hospital readmissions and improved patient outcomes. One of CCMS’ studies, show dramatic decreases in readmission rates, from the well-documented 17 percent average to as low as a 3 percent average, with CCMS’ integrated Hospital Readmission Reduction Program (HRRP) and post-acute care management services. The other study of chronic care patients shows that it can reduce acute care ER and admissions in a population of patients with a propensity to need acute care with CCMS’ advanced primary care management program. This study included 50 patients randomly selected with multiple severe chronic conditions over a 29-month period. There were over 1100 patient months involved with less than 1 percent of those months resulting in an acute-care stay.

ELEVATING THE STANDARDS OF POST-ACUTE CARE

CCMS positions primary care physicians as guides that allow patients to gain a unified continuity of care, where every decision and intervention is geared toward enhancing their quality of life. Whether through personalized care plans, proactive disease management, personalized preventive medical plan, or comprehensive support services, CCMS ensures patients emerge as the ultimate winners by improving health and quality of life outcomes.

From a provider standpoint, CCMS equips them with a wealth of information to make informed decisions and deliver tailored care solutions geared to optimize clinical practices and streamline care delivery processes for greater efficacy, increased professional fulfillment, and improved patient outcomes.

Today, the average hospitalization cost is $15,000, with additional care support adding to the overall expenditure. Providing a solution that increases low-cost preventative care and services provided to patients, CCMS’ models generate significant cost-savings for payers by reducing acute care hospital admissions, and readmissions, preventing disease complications, and optimizing resource utilization. CCMS’s innovative care management approach promotes best practices and cost-effective care delivery while ensuring the sustainability and viability of healthcare programs.

The success of CCMS’ care models hinge on achieving a delicate balance between delivering high-quality care and minimizing costs. This dual objective presents a formidable challenge, yet it holds immense potential for bringing transformative change in the healthcare landscape. Through a relentless focus on patient-centered care, data-driven decision-making, and collaborative partnerships across the care ecosystem, CCMS’ vision of a triple win continues to turn expectations into reality.